Job Description
**Your Future Evolves Here**
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.
Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.
Join Evolent for the mission. Stay for the culture.
**What You'll Be Doing:**
Put your passion where it meets purpose! Evolent attracts some of the brightest minds in health care. Surround yourself with talented, driven colleagues who share a passion for better health outcomes and a more connected care journey. We are hiring for an Investigator to join our Special Investigations Unit.
Evolent's Special Investigation Unit works closely with our health plan clients to identify, reduce and eliminate health care fraud, waste and abuse.
**Collaboration Opportunities:**
As an investigator with Evolent's Special Investigations Unit, you will have the opportunity to work closely with the Operations Team, Compliance, Utilization Management, and our partners at State Agencies and Law Enforcement. Our team of investigators work together to identify current fraud schemes, perform data analytics, conduct audits and educate providers.
**What You'll Be Doing:**
+ Performing target claim audits (desk and on-site) as directed; distributing audit reports by the required due date
+ Conducting investigations, including but not limited to, data analysis, record review, provider office inspections, and field observations
+ Communicating audit findings internally to the Special Investigations Unit, executive leadership and state or federal regulatory entities as needed
+ Serving as an integral attendee and contributor at Special Investigations Unit meetings
+ Gathering and reviewing data in response to inquiries sent to the Special Investigations Unit
+ Handling Fraud, Waste, and Abuse (FWA) hotline calls and e-mails, responding to messages received and tracking receipt of calls and e-mails
+ Assisting in development and implementation of FWA policies and procedures
+ Maintaining up-to-date notes and documentation on respective case load in the Investigation Database
+ Assisting in planning, development, and delivery of FWA related educational training for the company and providers
+ Acting as the Special Investigations Unit Liaison to assigned company departments to provide educational information and soliciting feedback
+ Maintaining confidentiality of all sensitive investigative/audit information
+ Performing other duties and projects as assigned
**Qualifications - Required and Preferred:**
+ Bachelor's degree preferred
+ 1-2 years of experience in FWA investigating in a healthcare operation
+ Knowledge of corporate investigative practices
+ Proficient understanding of medical terminology, human anatomy, medical tests and procedures, and health conditions
+ Leadership skills to effectively communicate with staff and regulatory representatives
+ Investigative, decision-making, problem solving, interpersonal and organizational skills
+ Consistent demonstration of accuracy, thoroughness and timeliness in completing work assignments; detail-oriented
+ Excellent ability to plan, organize and maintain multiple projects and files
+ Excellent verbal and written communication skills and interpersonal skills
+ Proficient experience using Outlook, Word, Excel and PowerPoint in a Windows operating system
+ Ability to adapt to fluctuating situations
+ Preferred 3-5 years of experience in FWA investigating in a healthcare operation
+ Preferred knowledge of healthcare services coding and claims billing
+ Preferred knowledge of Health Insurance, Managed Care, Benefit Design, and Federal Regulations
+ Preferred AHFI, CFE, and/or Certified Coder with either CPC, CCS or CMPA (*Certified Professional Coder, Certified Coding Specialist, Certified Professional Medical Auditor)
**Technical Requirements:**
We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.
**Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.** **If you need reasonable accommodation to access the information provided on this website, please contact** **
[email protected]** **for further assistance.**
The expected base salary/wage range for this position is $75,000. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.
Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!
Job Tags